Cord blood coagulation studies in infants of high-risk pregnant women

Serum Proteomic Signatures in Umbilical Cord Blood of Preterm Neonates Delivered by Women with Gestational Diabetes

Background

Women who develop diabetes during pregnancy are at higher risk of preterm birth. Here, we identified differentially expressed proteins (DEPs) in the serum of umbilical cord blood samples obtained from preterm neonates delivered by women with gestational diabetes to provide therapeutic targets for clinical drug development.

Materials and Methods

Umbilical cord blood was collected after delivery of preterm neonates by women with gestational diabetes and after delivery of healthy neonates by women without diabetes. DEPs in the serum samples were identified using liquid chromatography-tandem mass spectrometry. Gene Ontology (GO), cluster analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) were used to determine the biological functions associated with these DEPs. Enzyme linked immunosorbent assay was used to confirm the key DEPs.

Results

We found that 21 proteins were significantly upregulated, and 51 proteins were significantly downregulated in 72 DEPs in serum samples. GO analyses showed that the DEPs were mainly associated with the GO terms cellular process, biological regulation, cellular anatomical entity, and binding. KEGG signaling pathway analysis indicated that most of the upregulated DEPs were associated with the complement and coagulation cascades, Staphylococcus aureus infection, pertussis, HIF-1 signaling pathway and PPAR signaling pathway and that most of the downregulated DEPs were associated with the complement and coagulation cascades, dilated cardiomyopathy, pathways in cancer, Chagas disease, and hypertrophic cardiomyopathy. The results of KEGG pathway annotation and enrichment analyses indicated that changes in the complement and coagulation cascades may be importantly associated with preterm delivery of neonates by women with gestational diabetes. The key DEPs were confirmed by enzyme linked immunosorbent assay.

Conclusion

Our proteomics and bioinformatics analyses identified several key proteins and the complement and coagulation cascades pathway that warrant further investigation as potential novel therapeutic targets in preterm delivery among women with gestational diabetes.

Hemostasis in Neonates with Perinatal Hypoxia—Laboratory Approach: A Systematic Review

Birth asphyxia, with an estimated prevalence of 1 to 6 per 1,000 live births, may lead to multiorgan dysfunction due to impaired oxygen and/or blood supply to various organ systems, including the hemostatic system. Coagulopathy, a common complication of perinatal asphyxia, has been described since the 1960s. The aim of this study was to systematically review the literature for records on the use of hemostasis tests in the evaluation of coagulation disorders, in neonates who had suffered from perinatal hypoxia or asphyxia. We identified published studies by searching PubMed and Scopus, up until April 2022. The literature search retrieved 37 articles fulfilling the inclusion criteria of the review. According to the bibliography, thrombocytopenia is commonly associated with perinatal hypoxia/asphyxia. The thrombocytopenia is usually described as mild and platelets return to normal levels by the 10th day of life. Additionally, hypoxic neonates usually present with a hypocoagulable profile, as reflected by the prolongation of standard coagulation tests, including prothrombin time, activated partial thromboplastin time, and international normalized ratio, findings commonly associated with disseminated intravascular coagulation, and by the reduction of the levels of the physiologic inhibition of coagulation system. A few studies thus far using ROTEM/TEG in hypoxic neonates have come to the same conclusion as well; hypoxic newborns seem to be characterized by a hypocoagulable profile compared with healthy neonates. It should be emphasized, however, that standard coagulation tests provide only a rough estimation of the true bleeding or thrombotic risk of hypoxic neonates. On the contrary, viscoelastic methods seem to be more precise in the early detection of hemostasis disorders in the neonatal population. However, until now, there was uncertainty as to the most appropriate coagulation assays for diagnosis and management of coagulation derangement in neonates with perinatal hypoxia indicating the need for further research on this field.

Transient hypercoagulability in adult patients following open-heart surgery

The technique of thrombelastography was used to assess whether the phenomenon of hypercoagulability (accelerated coagulation) occurred in adult patients (n = 20) undergoing consecutive open-heart surgical procedures. Standard haematological investigations (pre- and 2 hours postop) were also performed and comparisons made with thrombelastographic parameters. Thrombelastographic hypercoagulability was identified in 12/20 (60%) cases but this event was transient occurring immediately postprotamine administration, and normalizing at 2h postoperation. The standard postoperative haematological assessments routinely made 2h after operation failed to detect this phenomenon. Hypercoagulability following cardiac surgery in adult patients merits further evaluation in order that the clinical significance may be determined.

Activated protein C resistance in cord blood from healthy and complicated newborns

OBJECTIVES

Newborns are susceptible to thrombosis secondary to the immature hemostatic system and maternal and fetal complications. The contribution of activated protein C resistance (APCR) to thrombosis tendency has not yet been established. This study was conducted to investigate the effects of maternal and fetal complications on APCR levels.

METHODS

APCR levels were determined in cord blood from healthy term infants and compared with those in healthy preterm and complicated neonates as well as that in adult venous blood.

RESULTS

The mean value of APCR in cord blood from healthy term infants (166 +/- 40 s) was not significantly different from that in adult venous blood (173 +/- 40 s). No significant differences in the mean cord blood APCR values were observed between healthy term and preterm infants, infants with vaginal and cesarean delivery, infants from preeclamptic and non-eclamptic mothers, and infants with or without perinatal asphyxia. The activity levels of protein C, protein S, and antithrombin III were not significantly different between these groups except for lower levels in preterm babies.

CONCLUSIONS

The level of APCR in cord blood is comparable to that in adults and not influenced by maternal and fetal complications. It appears that APCR does not contribute to the thrombotic tendency in newborns.

The evaluation and management of neonatal coagulation disorders

Neonatal hemostatic abnormalities can present diagnostic and therapeutic challenges to the physician. Developmental deficiencies and/or increases of certain coagulation proteins, coupled with acquired or genetic risk factors, can result in a hemorrhagic or thromboembolic emergency. The timely diagnosis of a congenital hemorrhagic or thrombotic disorder can avoid significant long-term sequelae. However, due to the lack of randomized clinical trials addressing the management of neonatal coagulation disorders, treatment strategies are usually empiric and not evidence-based. In this chapter, we will review the neonatal hemostatic system and will discuss the most common types of hemorrhagic and thrombotic disorders. Congenital and acquired risk factors for hemorrhagic and thromboembolic disorders will be presented, as well as current treatment options. Finally, suggested evaluations for neonates with either hemorrhagic or thromboembolic problems will be reviewed.

The coagulation system in placental insufficiency: a study in the fetal circulation

OBJECTIVE

To examine the hypothesis that Doppler-defined umbilical placental insufficiency is associated with intravascular coagulation in the fetal circulation.

DESIGN

A prospective, descriptive, single centre study.

SETTING

The University of Sydney, Department of Obstetrics at Westmead Hospital.

SUBJECTS

Ninety-one infants were classified on the basis of the systolic:diastolic (SD) ratio of the umbilical artery flow velocity waveforms into severe (SD > 99.9th centile), moderate (SD > 95th centile) or control groups.

INTERVENTION

Blood was collected from the umbilical vein at delivery.

MAIN OUTCOME MEASURES

The coagulation variables measured were the plasma concentrations of thrombin-antithrombin, fibrinopeptide A and fibrinogen, the antithrombin III activity, the prothrombin time and the activated partial thromboplastin time.

RESULTS

There were no differences in activated partial thromboplastin time, antithrombin III activity, fibrinopeptide A or thrombin-antithrombin complex concentrations between fetuses with placental insufficiency and those with no placental disease. Fetuses with severe and moderate placental insufficiency had a statistically significant prolongation of their mean prothrombin time compared to controls (23.7 +/- 0.8, 23.6 +/- 1.6, and 19.9 +/- 0.6 s, respectively). Infants in the severe group had a lower plasma fibrinogen concentration than control fetuses (1.66 +/- 0.09 and 1.94 +/- 0.09 g/l, respectively). The activated partial thromboplastin time and antithrombin III activity were both highly dependent on gestational age.

CONCLUSIONS

These results do not support the hypothesis that Doppler-defined umbilical placental insufficiency is associated with activation of coagulation in the fetal circulation.

Comparison of antithrombin III, protein C and protein S levels in capillary and venous blood of newborn infants

The plasma concentrations of antithrombin III, protein C and protein S in capillary and venous blood samples obtained simultaneously from 30 neonates were compared in order to determine the suitability of using capillary blood for estimation of these proteins with anticoagulant action. Our findings showed that while capillary and venous blood did not differ significantly in antithrombin III functional activity and protein C antigen levels, the capillary samples had significantly lower protein C functional activity and higher antithrombin III antigen level. Protein S antigen level was also significantly higher in the capillary samples although the difference was relatively small. The capillary and venous concentrations of the binding protein of protein S, C4b binding protein, were almost identical.

Abnormalities in vascular arachidonic acid metabolism in the infant of the diabetic mother

The infant of the diabetic mother has an increased incidence of thromboses in utero and in the neonatal period. In the adult with diabetes a decrease in prostacyclin formation has been suggested as a cause for the atherothrombotic tendency. We therefore evaluated arachidonic acid metabolism in infants of diabetic mothers. Endogenous radioimmunoassayable 6-keto prostaglandin F1 alpha (PGF1 alpha) was normal in umbilical vessels obtained from the infants of diabetic mothers whose glucose homoeostasis was maintained when compared with control values. Nevertheless, a significant inhibition of vascular production of 6-keto PGF1 alpha was observed in infants born to mothers with raised HbA1C concentrations. A decrease in the concentration of plasma 6-keto PGF1 alpha was also seen in the infants of diabetic mothers when compared with control neonates. The correlation observed between plasma 6-keto PGF1 alpha concentrations and endogenous vascular prostacyclin formation in the infants of diabetic mothers indicates that the in vitro deficiency of prostacyclin formation reflects a concomitant in vivo abnormality.

Post-natal development of protein C in full-term newborns

The purpose of this study was to determine the concentration of Protein C in the blood of full-term healthy newborns. The levels of Protein C, evaluated by electroimmunoassay, were low in the first 5 days of life and lower than the critical adult thrombotic level. The antigenic activity increased progressively from the 2nd week of life and the adult values were reached after the 6th month. The reduction of Protein C levels may impair the ability of the newborn to control consumptive disorders, thus exposing the infants to the risk of thrombotic conditions in neonatal age.

Influence of pre-eclampsia on concentrations of haemostatic factors in mothers and infants

The effect of pre-eclampsia on selected maternal and neonatal coagulation factors was studied by comparing plasma concentrations in 5 severely pre-eclamptic and 5 normal pregnancies. Pre-eclampsia was associated with appreciably lower maternal values of antithrombin III, plasminogen, and platelet count in late pregnancy but umbilical cord blood values showed no notable differences from normal pregnancy.

Cord blood platelet aggregation; quality control by a two-sample technique

Two blood samples were taken from the cords at 17 normal deliveries 2-4 min and 5-8 min after birth, respectively. The difference in platelet count between early and late samples in platelet-rich plasma was less than 5% in nine cords (Group A), and greater in eight cords (Group B). Platelet aggregation studies on the early and the late blood samples showed consistent results within each cord in Group A but not in Group B. The correlations between the responses were high for Group A. The aggregation responses were also slightly but significantly higher in the late samples in this group (p less than 0.01 in Group A; n.s. in Group B). The differences between responses in early and late blood samples could not be explained by acid-base dissimilarities. The variability in cord blood platelet aggregation results can be greatly reduced by platelet counting in PRP of two independent blood samples, accepting only samples with concordant platelet counts (less than 5% difference).

Rapid microanalysis of coagulation parameters by automated chromogenic substrated methods - application in neonatal patients

Daily monitoring of coagulation parameters in critically ill premature born neonates is only possible on small amounts of blood obtained by heelpuncture. Therefore, automated spectrophotometric micro-assays for antithrombin III (AT III), factors II and X, plasminogen and alpha 2 antiplasmin were applied on capillary and venous blood samples concurrently obtained in adults and healthy neonates. No statistically significant difference for any of the parameters was revealed. High levels of platelet factor 4 present in serial capillary samples of adults, did not interfere with the heparin dependent AT III assay. There was no evidence of thrombin or thromboplastin generation in these capillary samples, when examined for Va or VII activities. The levels of AT III, factors II and X and of plasminogen in neonates were 35-45% of the adult levels, in contrast to alpha 2 antiplasmin which was in the adult range.

Factor II (prothrombin) levels in cord blood: correlation of coagulant activity with immunoreactive protein

Hypoprothrombinemia occurs in newborn infants, but it is unclear whether this is the result of reduced production of Factor II precursor or a vitamin K deficient state. In this study, 76 cord blood specimens were analyzed for functional factor coagulant activity and levels of Factor II antigen as determined by electroimmunoassay. In 40 normal term infants, CA = 30% +/- 1.6 (mean +/- SEM) and Ag = 44% +/- 2.3; in 17 normal preterm infants CA = 30% +/- 1.0 and Ag = 31% +/- 4.2; and in 50 normal adults CA = 83 +/- 3 and Ag = 91 +/- 4. In the term infants the average ratio of CA:Ag was 0.90 and in the preterm infants 0.96, both values being similar to those in adults and suggesting underproduction of the precursor form. In 19 term infants who experienced complications of pregnancy and/or delivery, the ratio was 0.76; seven of these ratios were less than 0.70 (range 0.40 to 0.69). These data show that hypoprothrombinemia is common in infant cord blood and is most marked in preterm infants. In the normal infants the CA:Ag ratios were normal, suggesting that the hypoprothrombinemia is the result of reduced production of the protein and not of vitamin K deficiency. However, term infants with complications of labor and delivery had reduced CA:Ag ratios that were suggestive of vitamin K deficiency.

Haemostatic disorders and respiratory distress in the newborn

Coagulation and fibrinolysis studies were performed on 64 newborns; 16 premature infants with hyaline membrane disease (HMD), 17 newborns with other forms of respiratory distress syndrome (RDS) (8 of them were premature), 31 healthy newborns (11 of them were premature). All the babies were studied once in the first 48 hours of life. There was no significant difference between sick and healthy babies for 5 parameters; platelet count, factor VIII, fibrinogen, fibrin(ogen) degradation products, euglobulin lysis time. Factor II, VII and X were low in all infants, and premature infants had significantly lower levels compared to full term newborns. Factor V, plasminogen, alpha 2 macroglobulin (alpha 2M) and antithrombin III (AT III) levels were significantly lower in sick infants. Except for AT III, these deficiencies were not related to prematurity. No significant difference was found between HMD and other RDS. Of the 33 sick infants, 5 developed laboratory findings consistent with disseminated intravascular coagulation (DIC). The results indicate that the coagulation and fibrinolytic abnormalities reported are not specific to HMD.